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2023RCE > Neurological Emergencies (0-5%) Complete > Flashcards

Neurological Emergencies (0-5%) Complete Flashcards

1
Q

Status epilepticus

Status epilepticus: _____ min clinical or electrographic seizure activity OR
____ seizures without ______

Refractory status epilepticus: failure of __________

Management:
Don’t forget?

A

Status epilepticus

Status epilepticus: ≥ 5 min clinical or electrographic seizure activity OR
≥2 seizures without recovery in between

Refractory status epilepticus: failure of benzodiazepine + 1 AED occurs in 30%
of SE patients, 30% die

Management:
CHECK CAPILLARY GLUCOSE –> thiamine 100 mg IV, D50 (50 mL IV)

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2
Q

Status epilepticus: Initial Management

_______ + _______

A

Status epilepticus: Initial Management

1 Abortive + 1 Maintenance

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3
Q

Refractory Status Epilepticus

Management:
_________________________
_________________________
_________________________
_________________________
Monitor for _____ with _____

A
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4
Q

Definition of Epilepsy

___________ seizures _____h apart
OR
_________ with _____ % recurrence risk
OR
_______ syndrome

A

Definition of Epilepsy

≥2 unprovoked seizures >24h apart
OR
1 unprovoked seizure with >60% recurrence risk
OR
Epilepsy syndrome

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5
Q

Epilepsy Classification

Focal:
EEG? ______________
Rx? ______________

Generalized
EEG? ______________
Rx? ______________

A

Epilepsy Classification

Focal:
EEG? Focal IEDs, slowing
Rx?: Epilepsy surgery

Generalized
EEG?: Generalized spike & wave
Rx?:
- AEDs
- Vagal nerve stimulator
- Ketogenic diet

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6
Q

Seizure vs Syncope vs TIA vs Migraine Aura

A
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7
Q

Seizure:
Risk of recurrence

Ø After first seizure ~______% risk of recurrence, greatest in first ____y
(treatment lowers ____y recurrence risk but not _______ risk)

Ø _____% if abnormal EEG or MRI

A

Seizure:
Risk of recurrence

Ø After first seizure ~21-45% risk of recurrence, greatest in first 2y
(treatment lowers 2y recurrence risk but not longterm risk)

Ø ≥ 60% if abnormal EEG or MRI

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8
Q

AEDs:

Which ones to avoid in idiopathic generalized epilepsy?
Why?

A

Carbamazepine*
Oxcarbazepine*
Phenytoin*
Eslicarbazepine*
Gabapentin*

Why? They can paradoxically worsen seizures

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9
Q

AEDs safe in Pregnancy?

A

Levetiracetam
Lamotrigine (choose this for associated bipolar disorders)

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10
Q

How to pick a first AED?

A
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11
Q

Counseling patients with epilepsy
CMA Driving Guidelines:

Ø First seizure, unprovoked: _______ months

Ø Epilepsy: _______ months seizure-free on medication

Ø Medication change: _________ months

A

CMA Driving Guidelines:

Ø First seizure, unprovoked: 3 months

Ø Epilepsy: 6 months seizure-free on medication

Ø Medication change: 3 months

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12
Q

AEDs:
Adverse effects: “SCARED-P” mnemonic
ØOsteoporosis

ØHyponatremia: __________, __________, __________

ØPsychiatric/irritability: __________

ØStevens-Johnson syndrome: __________, __________, __________, __________

ØPR-prolongation: __________

ØWeight gain: __________

ØWeight loss: __________

ØCognitive impairment: __________, __________

ØSedating: __________, __________

A

Adverse effects: “SCARED-P” mnemonic
ØOsteoporosis

ØHyponatremia: carbamazepine, oxcarbazepine, eslicarbazepine

ØPsychiatric/irritability: levetiracetam

ØStevens-Johnson syndrome: phenytoin, lamotrigine, carbamazepine, oxcarbazepine

ØPR-prolongation: lacosamide

ØWeight gain: valproate

ØWeight loss: topiramate

ØCognitive impairment: topiramate, clobazam

ØSedating: clobazam, phenobarbital

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13
Q

Guillain-Barré Syndrome
Treatment?

For nonambulatory patients within ______ weeks of symptoms,

_____________________ over ____ days
OR
______________________

_________ NOT recommended in GBS.

No role for sequential or repeat ___________ treatments

A

For nonambulatory patients within 4 weeks of symptoms,

Intravenous immunoglobulin (IVIg)
2g / kg divided over 2-5 days
OR
Plasmapheresis (PLEX)

Steroids are NOT recommended in GBS.

No role for sequential or repeat IVIg treatments

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14
Q

GBS:
Elective intubation if?

A
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15
Q

_________ can mimic GBS

Investigation to differentiate?

A

Acute myelopathy can mimic GBS

Ø MRI whole spine + Gad
– Nerve roots & cauda equina may enhance, also r/o acute myelopathy (mimic)

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16
Q

The typical pattern of neuropathy and Red flags?

A
17
Q

Myasthenia Gravis:

Symptoms?

A

Fatiguable weakness primarily of:

Ocular: ptosis, binocular diplopia, pupil-sparing

Bulbar: dysarthria, dysphagia, chewing fatigue, head drop

Respiratory: orthopnea

Extremities: proximal > distal weakness, and intense fatigue

18
Q

Myasthenia Gravis:

Investigations?

A

Investigations
ØFVC/PFTs

ØSerum AChR Ab (±MuSK, LRP4): 80% generalized MG, 50% ocular MG

ØEMG/NCS
ØSFEMG: Single-fibre EMG of frontalis, orbicularis oculi for enhanced jitter (Sn 95%, nonspecific)
ØRNS: Repetitive nerve stimulation for decrement (Sn75% Sp 90%)

ØCT chest to r/o thymoma (10% MG pts)

ØCBC, electrolytes, Cr

ØTSH, CK

19
Q

Acute Management of myasthenic crisis

___________ (Preferred)
OR
___________

Hold ____________ when intubated (manage airway secretions)

Don’t use _______________

A

Plasmapheresis (PLEX)
Preferred by consensus opinion for rapidity of action

OR

Intravenous immunoglobulin (IVIG)
2g/kg over 2-5d

Hold pyridostigmine when intubated (manage airway secretions)

High-dose prednisone CAUTION!
<50% transient worsening of respiratory status in 5-10d

20
Q

Maintenance treatment of myasthenia gravis

Symptomatic?

Disease-Modifying Therapy?

A
21
Q

Role of thymectomy in myasthenia gravis

Thymoma + (10%): ___________

Thymoma negative: Elective thymectomy if:
____________
____________
____________

A

Role of thymectomy in myasthenia gravis

Thymoma + (10%): Refer to thoracic surgery for thymectomy

Thymoma negative: Elective thymectomy if:
Ø <60 years
Ø AChRAb+
Ø Disease duration <5y

22
Q

Drugs to avoid in myasthenia?

A

Drugs to avoid in myasthenia:

Ø Anesthetic agents (neuromuscular blockade)

Ø Antibiotics (fluoroquinolones, macrolides, aminoglycosides)

Ø Cardiovascular drugs (beta-blockers, procainamide, quinidine)

Ø Anti-PD-1 monoclonal antibodies (e.g. nivolumab, pembrolizumab)

Ø Botulinum toxin

Ø Chloroquine, Hydroxychloroquine

Ø Magnesium, lithium

Ø Glucocorticoids CAUTION in myasthenic crisis!

23
Q

Red flags in headache?

A

Red flags in headache: SNOOP4

Systemic: fever, weight loss, immunosuppression (HIV, steroids, cancer, pregnancy)

Neurological symptoms/signs (meningismus, encephalopathy, papilledema)

Onset thunderclap: peaks <1min

Older > 50y

Pattern Δ, Positional, Pulsatile tinnitus, Precipitated by cough or Valsalva

24
Q

Headache differentials:

A
25
Q

Treatment of status migrainosus

A
26
Q

6 spinal cord syndromes

A
27
Q

Multiple sclerosis: Typical syndromes

A
28
Q

Revised Macdonald criteria for RRMS - Relapsing-remitting Multiple Sclerosis- 2017

A
29
Q

Treating MS attacks

A
30
Q

Vertigo.
Differentials?

A
31
Q

Posterior reversible encephalopathy syndrome

A

2023RCE (20 decks)

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